George Orwell said, “If people cannot write well, they cannot think well, and if they cannot think well, others will do their thinking for them.” If Orwell was right, the profession of medicine and the patients it cares for could be in big trouble. As a result of ongoing changes in healthcare, today’s medical students and residents are being asked to write much less than in the past, with a predictable decline in the quality of what they produce. This, in turn, threatens the quality of patient care.
Recently one of our medical students, a very bright young man, submitted his first patient write-up. He had spent several hours interviewing the patient, performing a physical exam, and recording his findings. Inspecting his work, we told him, “This is not good medical writing. What you have produced is not a note fit for a patient’s chart but a series of bullet points.” He replied, “But that’s how I think — I think in bullet points. Why should I write any differently?”
He had a point. He and many — perhaps most — of his colleagues really do think in bullet points. Raised on a steady diet of terse emails, abbreviation-laden text messages, and telegraphic tweets, their routine modes of written communication exhibit a clipped, disjointed quality. Too often, isolated impressions tumble forth one over another, with very little in the way of a coherent, sustained theme to bind them together.
The decline in medical writing has other sources, such as the widespread use of PowerPoint in education. When nearly every medical school lecture is formatted in bullet points, why should students suppose that they are expected to produce anything different? The same approach is found among many textbooks, which often eschew the use of complete sentences. Another factor promoting bullet-point thinking is the ubiquitous replacement of essays by multiple-choice tests.
Yet we believe there is an even more pervasive force behind the declining quality of writing in medicine. It is the medical record itself, which has moved from handwritten pages in loose-leaf binders to electronic forms and templates. Instead of telling a patient’s story in prose, today’s medical learners are required merely to tick boxes, review auto-populated forms, and copy and paste chunks of text from one entry to another.
Not only are medical students less frequently required to compose integrated narratives, but they are also devoting less time to confirming the elements they do record. At first, pasting blocks of text seems to provide a welcome short cut, but it soon becomes a new norm, with erosive effects for both the accuracy of the medical record and the veracity of the physician. When students don’t formulate their own ideas, critical thinking and analysis inevitably suffer.
The driver in this dumbing down of the medical record is not primarily the best interests of patients — making medical records more user-friendly, knowledge-rich, and useful in patient care. Instead, it is coding and billing. Medical practices, hospitals, and health systems are loath to “leave money on the table,” and so they require physicians to enter health information in ways that maximize its value as a commodity.
The length of entries in patients’ charts has grown exponentially. Why? If something is left out, payment may be denied. Yet the quantity of medical knowledge has not increased. Truly valuable information is diluted by formulaic drivel, making it more difficult to locate what the health professional really needs to know. Many colleagues have commented that, in today’s medical record, the care of the patient too often seems an afterthought.
The days when making entries in the medical record challenged young doctors to synthesize and integrate what they were learning about their patients are fast fading from memory. Even if all the information really is captured — and for reasons we outline below, we doubt that it is — it is unlikely to be fully understood and acted on. First it must first be formulated into a coherent narrative, a story that weaves together the biology and the biography of the patient.
Such integration makes a difference. A woman being treated for cancer had a history of asthma and abnormal heart rhythms. The oncologist reviewing her record asked if her episodes of dysrhythmia were associated with the use of her inhaler, which delivers a drug that stimulates the heart. Once she modified her use of the inhaler, the heart problems went away. Her pulmonologist and her cardiologist never wrote a comprehensive note, and as a result, they never put two and two together.
Today’s doctors in training are too often functioning as data entry specialists, no longer eliciting, recording, or understanding the patient’s story. We forget that really first-rate medicine resembles creative writing. When the patient’s story is fragmented into ticked boxes, auto-populated fields, and pasted chunks of verbiage, key elements remain unintegrated, inconsistencies go uncorrected, and opportunities to tie things together are missed.
It is not just a matter of reducing medical errors. Getting the full story is equally crucial in caring for the patient as a person. In another case, a student emerged from an encounter with an elderly cancer patient and gave a competent bullet-point style account of what he had learned. He had dutifully gathered all the information required by the template on his tablet computer, including even sensitive matters such as sexual history and end-of-life care.
What was completely missing from the student’s account, however, was any sense of who the patient was, what kind of life he had led, and what he hoped for from his care. Such information is not part of any quality metric, nor is it needed to code and bill accurately for the encounter. From some points of view, such information might be branded mere chit-chat, nothing more than pleasantries exchanged to prevent patients from thinking their doctor sees them as a disease and nothing more.
But there is far more to it than this. The attending physician returned with the student and spent an additional 15 minutes with the patient. During this time, he learned that the patient holds a PhD in a foreign language and had spent decades in the intelligence service. Early in his career, he had been captured and tortured before finally being liberated. Undeterred, he returned to the intelligence service and met a woman fleeing persecution, whom he later married.
In the course of this conversation, both the medical student and the attending physician gained a deeper understanding of the patient, with important implications for his care. Yet they also learned some fascinating things about a world they had never encountered before. More notably, toward the end of the conversation, the patient’s wife reached over and took the attending physician’s hand in her own, saying, “My husband has seen many doctors, but you are the first one to ask questions about his life. I just wanted to thank you for treating him as a person.”
Why did the attending physician get this information? Not because he was populating a field on a computer screen, but because he was genuinely interested in the patient. If he knew the story better, he would be able to take better care of the patient.
We are not suggesting that physicians who trained before the era of the electronic health record were all great writers. We are simply concerned about what will happen if writing continues to sink beneath the horizon of medical training. How will medical students learn to think critically and know when to diverge from established algorithms? How will they grasp the vital role that knowing the patient’s story should play in medical practice?
Such questions are beginning to receive attention. The reformatted Medical College Admissions Test now includes a section on critical analysis and reading skills. Some medical schools are challenging applicants to write reflective essays, and the same thing is occurring when graduating students apply to residency programs. Some schools have also developed programs in narrative medicine. But more efforts are needed, and they cannot be confined to medical schools.
To be sure, medicine is a science, and it is also an important form of economic activity. Both depend on data, and today’s doctors are generating such data by the gigabyte. But medicine is also an art, and the artful side of medicine lives not by data but by narratives. Patient management may be driven by data, but it is often the story more than anything else determines how well the patient is cared for.
Editor’s Note: A version of this piece first appeared at KevinMD.com on February 20, 2016.